Gold criteria 2019

Dr. Md. A. Hadi
IMO
Dept. of Medicine, SWMCH
Brief Summary on Updates of GOLD-2019
Guidelines

Chronic Obstructive Pulmonary Disease
(COPD)
► COPD is currently the fourth leading
cause of death in the world.
► COPD is projected to be the 3rd leading
cause of death by 2020.
► Globally, the COPD burden is projected
to increase in coming decades because
of continued exposure to COPD risk
factors and ageing of the population.
© 2019 Global Initiative for Chronic Obstructive Lung Disease

►Estimated global
prevalence of
COPD-11.7%
(95% CI 8.4%–15.0%).
►Three million deaths
occur annually.
Prevalence of COPD

COPD Definition
► Chronic obstructive pulmonary
disease (COPD) is defined as a
preventable and treatable disease
characterized by persistent
airflow limitation that is usually
progressive and associated with
an enhanced chronic inflammatory
response in the airways and the
lung to noxious particles or gases.

Causes & Risk
factors:
► Environmental factors
- Tobacco smoke.
- Indoor air pollution (biomass exposure).
- Occupational exposures.
- Low birth weight.
-Infections.
-Low socioeconomic status.
► Host factors
- Genetic factors: α1-antitrypsin deficiency.
-Asthma & Airway hyper-reactivity.

 Chronic & progressive
dyspnea
 Cough
 Sputum production  Wheezing and chest
tightness
►Symptoms of COPD

B- Diagnosis OF COPD
SPIROMETRY
Required to
establish
diagnosis
SYMPTOMS
•Shortness of
breath
•Chronic cough
•Sputum
RISK
FACTORS
•Host factors
•Tobacco
•Occupation
•Indoor/outdoor
pollution

Spirometry diagnosis
Spirometry is required to make
the diagnosis:
The presence of a post-
bronchodilator FEV1/FVC < 0.70
confirms the presence of persistent
airflow limitation.

Spirometry

ABCD assessment tool
CAT: COPD AssessmentTest mMRC: modified Medical Research Council

Post-bronchodilator FEV1

COPD Assessment Test (CATTM)

Modified MRC dyspnea scale

Assessment of Exacerbation Risk
► COPD exacerbations are defined as an acute worsening of
respiratory symptoms that result in additional therapy.
► Classified as:
 Mild (treated with SABAs only)
 Moderate (treated with SABAs plus antibiotics and/or oral
corticosteroids) or
 Severe (patient requires hospitalization or visits the
emergency room). Severe exacerbations may also be
associated with acute respiratory failure.
► Blood eosinophil count may also predict exacerbation rates.

ABCD Assessment Tool
• Example:
► Consider two patients:
 Both patients with FEV1 < 30% of predicted
 Both with CAT scores of 18
 But, one with 0 exacerbations in the past year
and the other with 3 exacerbations in the past year.
► With the new proposed scheme, the subject with 3 exacerbations in the
past year would be labelled GOLD grade 4, group D.
The other patient, who has had no exacerbations, would be classified as
GOLD grade 4, group B.

D- Management
of
COPD
“Golden Quotations &Statements from the GOLD-2019”

“Inhaled bronchodilators in COPD are central to symptom management and
commonly given on a regular basis to prevent or reduce symptoms” “Evidence
A”
“Regular and as-needed use of SABA or SAMA improves FEV1 and
Symptoms” “Evidence A”
“LABAs and LAMAs significantly improve lung function, dyspnea,
health status, and exacerbation rates” “Evidence A”

“Combination treatment with LABA and LAMA
increases FEV1, and reduces symptoms compared to monotherapy”
“Evidence A”
“Combination treatment with LABALAMA reduces
exacerbations compared to monotherapy” “Evidence B”
“LAMAs have a greater effect on exacerbation reduction compared with
LABAs” “Evidence A”

“Combining bronchodilators with different mechanisms and durations of
action may increase the degree of bronchodilation with a lower risk of
side-effects compared to increasing the dose of a single bronchodilator”
“Treatment with Formoterol and Tiotropium in separate inhalers
has a bigger impact on FEV1 than either
component alone”
Recommendations of GOLD-2019
for Combination Bronchodilator
therapy

Inhaled Corticosteroids (ICS):
“Long-term monotherapy with ICS is not recommended” “Evidence A”
“An ICS combined with a LABA is more effective than the individual
components in improving lung functions and reducing exacerbations in
patients with exacerbations and moderate to severe COPD”
“Evidence A”

“Regular treatment with ICS increases the risk of
Pneumonia especially in those with Severe COPD”
“Evidence A”
“Long-term use of Oral glucocorticoids has numerous side-effects with
no evidence of Benefits” “Evidence A”

“ICS/LABA Combination
decreases exacerbations to
a greater extent than an
LABALAMA combination at
higher blood eosinophil
concentrations”

Blood Eosinophil count
Eosinophilia is a disorder associated
with Eosinophils count higher than 500
eosinophil cells per micro liter of blood
and it can result from parasitic
infections, asthma, allergic-rhinitis,
eczema or malignant tumors.

GOLD-2019 Guidelines
introduced
Blood Eosinophil Count with a
cut off of 100 cells per micro
liter as a Biomarker for
estimating the efficacy of
Inhaled Corticosteroids (ICS)
for the prevention of
exacerbations.

Blood Eosinophil's count as a predictor of the
ICS impact
“Blood eosinophil count predicts the magnitude
of the effect of ICS
(added on bronchodilator treatment) in preventing
future exacerbations”
“ICS containing regimens
have NO effect on
exacerbations at
a blood eosinophil count
less than
100 cells/microliter”
“This threshold can
be used to identify
patients with a low
likelihood of
treatment benefit
from ICS”

Blood Eosinophil's count as a predictor of the
ICS impact
“The threshold of a blood eosinophil count
higher than 300 cells/microliter identify
patients with the greatest likelihood
of treatment benefit with ICS”
“Blood eosinophil counts can be
used as a biomarker when making
decisions regarding ICS use”

Pharmacological treatment algorithms of stableCOPD
2 Separate algorithm models
Initiation treatment Algorithm Follow-up treatment Algorithm
Based on ABCD Assessment
scheme of symptoms &
exacerbation risk
For patients taking maintenance
treatment whether early after
initial treatment or after years
of follow-up.

COPD GOLD Guidelines 2019
Categorize
into COPD
GOLD A-D
Initiate 1st
Line
therapy
Follow-up based
on further
DYSPNOEA or
EXACERBATIONS

Treatment of stable COPD
Definition of abbreviations:
eos: blood eosinophil count in cells per microliter; mMRC: modified Medical Research Council
dyspnea questionnaire; CAT™: COPD Assessment Test™.

Group A
► All Group A patients should be offered bronchodilator treatment based
on its effect on breathlessness.
► This can be either a short- or a long-acting bronchodilator

Group B
► Initial therapy should consist of a long acting bronchodilator
► (LABA or LAMA).

Long-acting inhaled bronchodilators are superior to
short-acting bronchodilators (taken as needed) and
are therefore recommended.
Group B
► For patients with
severe breathlessness
initial therapy with:
► two bronchodilators
may be considered.

Group C

►Initial therapy should consist of a
single long acting bronchodilator.
►In two head-to-head comparisons
the tested LAMA was superior to
the LABA regarding exacerbation
prevention therefore we
recommend starting therapy with
a LAMA in this group.
Group C

Group D

► In general, therapy can be started with a LAMA
as it has effects on both breathlessness and
exacerbations.
► For patients with more severe symptoms (CAT™ ≥
20), especially driven by greater dyspnea
LAMA/LABAmay be chosen as initial treatment
where LABA/LAMA combinations showed
superior results compared to the single
substances.
Group D

► ICS may cause side effects such as pneumonia, so should be used as initial
therapy only after the possible clinical benefits versus risks have been
considered.
► In patients with blood eosinophil
counts ≥ 300 cells/µL .
► LABA/ICS may also be first choice in
COPD patients with a history of
asthma.
Initial therapy with LABA/ICS may be the first
choice as it has the greatest likelihood of
reducing exacerbations
Group D

 If Response to initial treatment is appropriate, Maintain it.
 If NOT, consider the predominant target of
treatment:
Dyspnoea OR Exacerbations
Use exacerbation pathway if both exacerbations & Dyspnoea
are needed to be targeted.

► For patients with persistent breathlessness or exerciselimitation
on long acting bronchodilator monotherapy,
 the use of two bronchodilators is recommended.
FOLLOW-UP pharmacological treatment
 Dyspnoea
► For patients with persistent breathlessness or exercise limitation
on LABA/ICS treatment,
 LAMA can be added to escalate to triple therapy.
 Alternatively, switching from LABA/ICS to LABA/LAMA should be
considered if the original indication for ICS was inappropriate

► Blood eosinophil counts may identify patients with a
greater likelihood of a beneficial response to
ICS.
 Exacerbations
 For patients with persistent exacerbations on long acting bronchodilator
monotherapy, escalation to either LABA/LAMA or LABA/ICS isrecommended
► LABA/ICS may be preferred for patients with a historyor
findings suggestive ofasthma.

► For patients with ≥ 2 moderate exacerbations per year or at
least one severe exacerbation requiring hospitalization in the
prior year,
► LABA/ICS treatment can be considered at blood eosinophil
counts ≥ 100 cells/µL, as ICS effects are more pronounced in
patients with greater exacerbation frequency and/or severity.
► For patients with one exacerbation per year, a peripheral
blood level ≥ 300 eosinophils/µL identifies patients more
likely to respond to LABA/ICS treatment.
 Exacerbations

 Exacerbations
In patients who develop further exacerbations on LABA/LAMA therapy
we suggest two alternative pathways
Blood eosinophil counts < 100 cells/µL
low likelihood of a beneficial
ICS response
 Add roflumilast or azithromycin
Blood eosinophil counts ≥ 100 cells /µL,
 Escalating to LABA/LAMA/ICS
(A beneficial response after the
addition of ICS may be
observed with higher
eosinophil counts).

COPD & comorbidities
 COPD often coexists with other diseases (comorbidities) that may have a
significant impact on disease course.
 In general, the presence of comorbidities should not alter COPD
treatment and comorbidities should be treated per usual standards
regardless of the presence of COPD.
 Lung cancer is frequently seen in patients with COPD and is a main
cause of death.

Contd…
 Cardiovascular diseases are common and important comorbidities in
COPD.
 Osteoporosis and depression/anxiety are frequent, important
comorbidities in COPD, are often under-diagnosed, and are associated
with poor health status and prognosis.
 Gastroesophageal reflux (GERD) is associated with an increased risk of
exacerbations and poorer health status.
 When COPD is part of a multimorbidity care plan, attention should be
directed to ensure simplicity of treatment and to minimize
polypharmacy.

Gist in a nutshell
1. There is a growing evidence of indoor biomass exposure to modern &
traditional fuels used during cooking may predispose women to develop
COPD in many developing countries. (Sana et al. 2018)
2. A new biomarker in the form of circulating eosinophil is introduced in
management protocol.
3. Polyvalent pneumococcal vaccination provides protection against
community acquired pneumonia, also reduced the likelihood of a COPD
exacerbations. (Walters et al. 2017)

CONTD…
4.The algorithms for the initiation & follow-up management of
pharmacological treatment have been revised.
5. Nebulized budesonide alone may be a suitable alternative for treatment
of exacerbations in some patients instead of intravenous
methylprednisolone. (Maltais et al., 2002, Gunen et al., 2007, Stallberg et al.,
2009)
6.Intensified combination therapy with ICS/LABA for 10 days at URTI onset
could be associated with a reduction of exacerbations, particularly in
patients with severe disease. (Stolz et al., 2018)

Gold criteria 2019

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Gold criteria 2019